Provider Demographics
NPI:1245572379
Name:BROADWAY SMILES DENTISTRY AND ORTHODONTICS, LLP
Entity Type:Organization
Organization Name:BROADWAY SMILES DENTISTRY AND ORTHODONTICS, LLP
Other - Org Name:BROADWAY SMILES DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAIRCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-750-1000
Mailing Address - Street 1:2860 MICHELLE DRIVE 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606
Mailing Address - Country:US
Mailing Address - Phone:714-368-2077
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:5545 E BROADWAY BLVD STE 107
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3809
Practice Address - Country:US
Practice Address - Phone:520-750-1000
Practice Address - Fax:520-750-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ74621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty